TOWN OF MILTON, N.H. WELFARE DEPARTMENT

Transcription

1 TOWN OF MILTON, N.H. WELFARE DEPARTMENT APPLICATION FOR ASSISTANCE ALL INTERVIEWS FOR ASSISTANCE ARE BY APPOINTMENT FOR AN APPOINTMENT CALL Ext. 9 Town of Milton, N.H. Application for Assistance Page 1

2 NOTICE OF RIGHTS OF ANYONE RECEIVING ASSISTANCE FROM THE MUNICIPALITY OF MILTON, N.H. You have the following rights: 1. You have a right to make a written application for assistance, even if the welfare officer tells you that you are not eligible. 2. You have a right to receive a prompt written decision telling you whether or not you will receive assistance each time you apply for assistance. 3. You have a right to have in writing the reason why you have been denied assistance or have been given only some of the assistance you requested. 4. You have a right to appeal any decision you do not agree with. You must appeal within five (5) working days after you received your decision. 5. You have a right to have a hearing to present your case. 6. You have a right have your assistance continued if you are already receiving assistance when you request a fair hearing. 7. You have a right to review the information in your file before your hearing. 8. You have a right to see the guidelines used by the welfare officer in making decisions on your application. 9. You have a right to be given a written notice of conditions before you are suspended from receiving assistance for failing to obey the guidelines. 10. You have a right to refuse to participate in municipal workfare program or to conduct a job search if you must care for a child under the age of five (5), if you are disabled or ill, or if you must take care of a member of your family who is disabled or ill. Town of Milton, N.H. Application for Assistance Page 2

3 Applicant Name: Social Security Number: Address: Town of Milton Welfare Department P.O. Box 310, Milton N.H Phone ext 9 Fax REQUIRED VERIFICATIONS Date: D.O.B.: Phone: In order to complete your request for assistance, we will need to verify certain types of information. Please bring with you as many of the following documents as may apply to your situation. Completed Application Form Last four weeks pay-stubs or other proof of wages Last four week s receipts or other proof of bills paid or currently due You have applied for / are receiving Social Security benefits You have applied at the HHS District Office for: Emergency Food Stamps Food Stamps TANF TANF Emergency Assistance Title XX Daycare APTD/MA OAA You have applied for / are receiving Fuel Assistance benefits Verification of injury or illness You have applied for / are receiving Unemployment Compensation If available, picture ID (Adults); Birth certificate/ss card (minors) Savings and checking account, liquid asset statements, bankbooks Statement child support payments received / Child support court order I understand that failure to provide the indicated information may result in delay and/or denial of my request for assistance, and I understand that if approved for assistance I may be required to do a job search and participate in workfare. Applicant Signature Town of Milton, N.H. Application for Assistance Page 3

4 TOWN OF MILTON, N.H. APPLICATION FOR ASSISTANCE Date of Application Referred by 1. General Information: Name Date of Birth Address Telephone Social Security number US Citizen? Marital Status Rent or Own? How long at this address? Spouse/Co-Applicant Name SS# Spouse address (if not same as applicant) Assistance Requested Reason for request Have you applied for local assistance before? When? Where? Under what name? List below all persons living in your household: Full Name Relationship Date of Birth Social Security # If at your current address less than 12 months, please list past 12 month s addresses: Street Town/City State Dates of Residence Town of Milton, N.H. Application for Assistance Page 4

5 2. Housing Information: Rent amount per (month/week) Date last paid Date due Do you have a current: Demand For Rent Notice to Quit Landlord/Tenant Writ Total rent owed Do you have a housing subsidy? Utilities Included: Heat Electric Gas Water/Sewer Other LANDLORD: Name Telephone Address IF HOME-OWNER: Mortgage Amount Date last paid Owed Bank/Mortgage Co Address 3. Education / Training / Employment Highest Grade G.E.D. or Military Attended Diploma Special Training or Skills Service Applicant: Spouse/Co-Applicant: Applicant Work History: Are you employed now? Employer Position When began work Date/Amount of most recent check Are you unemployed now? Reason Date last worked Employer Date/Amount last check Are you able to work now? If not able, why not? Current and two most recent jobs of you and all household members aged 18 & older: Weekly/ Employment Reason for Name Employer Pay Biweekly Dates Leaving Town of Milton, N.H. Application for Assistance Page 5

6 4. Household Assets: Provide information regarding accounts held by you and all household members: Savings Savings Checking Checking Name Bank/Credit Union Acct. # Balance Acct. # Balance Provide current value of any assets held by you and all household members: Cash on hand (all household combined) Certificates of Deposit (CD s) Savings Bonds Mutual Funds Annuities Stocks Trust Funds Retirement Accounts Insurance Policies (cash value) 401k Property other than primary residence Location Other Investments Motorcycles/Boats/Snowmobiles/ATV s/rv s Other Assets (please list) Claims/settlements/income due to you or any household member IRS Refund Insurance Claim Retroactive disability check Retroactive Unemployment or Worker s Compensation check Inheritance Other Lump Sum Payment (explain) Have you or any household member consulted a lawyer regarding a possible lawsuit?: Lawyer Name/Address Reason Do you or any household member have a lawsuit pending? Who? Please give details Lawyer Name/Address Motor vehicles owned by you and all household members: Owner Auto Make Model Year Value Payments Insurance Town of Milton, N.H. Application for Assistance Page 6

7 5. Household Income Indicate any benefits or income received or applied for by you or any household member: Name Date Date Last Monthly Applied Received Amount ANB (Aid to the Needy Blind) APTD Child Support Disability (Employer) Food Stamps Fuel Assistance Gifts/Loans Maternity Benefits Medicaid OAA (Old Age Assistance) Retirement Severance Pay Social Security SSDI (SS Disability) SSI (Supplemental Security) TANF Unemployment Vacation Pay Veteran s Pension Vocational Rehabilitation WIC(Women/Infants/Children) Worker s Compensation Other: [ ] Are you or any other household member working, volunteering, and/or receiving assistance from any other agencies? Name Agency Name Contact Person Town of Milton, N.H. Application for Assistance Page 7

8 6. Household Expenses List actual or estimated regular monthly expenses. (Not all expenses will be allowable to be included in your eligibility determination, but all should be listed to show your financial situation.) Bank Fees Diapers Mortgage Bus/Cab Electric Prescriptions Cable/Internet Food Rent Child Support Paid Fuel Oil Rent-To-Own Car Gasoline Gas, Bottled School Loan Car Insurance Gas, Natural Storage Car Payment Health Insurance Telephone Condo Fee Laundry Other Child Care Loan Other Credit Card Lot Rent Other List unplanned, emergency or irregular periodic expenses during the past 30 days: Car Inspection Driver s License Medical Car registration Fines/Court Payments Sewer/Water Car repair Home Repairs Tax (Income/Property) Dental Home/Rent Insurance Other 7. Criminal Information Have you or any member of your household ever been convicted of a felony which has not been annulled? (yes/no) If yes, who? When? Town/City & State of conviction Details of conviction: Are you or any member of your household presently on parole or probation? (yes/no) If yes, who? Court or jurisdiction? Name & phone number of parole/probation officer 8. Liability for Support Information Please provide following details: Your father Address Your mother Address Co-applicant father Address Co-applicant mother Address Your or co-applicant s adult children Town of Milton, N.H. Application for Assistance Page 8

9 9. Certifications and Signatures I understand that if I receive assistance from the municipality I may be required to participate in the welfare work ( workfare ) program. (RSA 165:31) I understand that I may be required to repay any assistance provided, after deduction of the value of workfare hours I have completed, if I am returned to an income status which enables me to reimburse without financial hardship. (RSA 165:20- b). I understand that if I am assisted the municipality may place a lien against any real property which I own. (RSA 165:28) I hereby certify that if I have a lawsuit, worker s compensation claim, or aid from any other social service agency now pending, I have listed these in this application. I further agree to notify the Welfare Official immediately upon receipt of any money from or upon the settlement of such claim. I understand that if I am assisted, the municipality may place a lien against any property settlement or civil judgment for personal injuries which I receive within six years of receiving municipal assistance. (RSA a) I hereby certify that the information I have provided on this application is complete to the best of my knowledge and belief and provides a true summary of my income, assets and needs. I understand I may be required to provide documents and/or other forms of verification to prove the information requested on this application. I hereby certify that all information I will provide in response to questions asked by the welfare official is true and complete to the best of my knowledge and belief. I understand that if I knowingly give false information or withhold information related to my receipt of assistance, now or in the future, I may be prosecuted for the crime of Unsworn Falsification (RSA 641:3) I understand that if I obtain a job after I am assisted by the municipality, and I later quit the job without good cause, I may be ineligible for local assistance from the municipality and any other New Hampshire municipality for a period of up to ninety days. (RSA 165:1-d) I understand that if I am a recipient of Temporary Assistance for Needy Families (TANF) cash benefits and I fail to comply with TANF regulations, leading to a sanction and loss of income, the municipality may, under certain circumstances, disregard this decrease in my income. (RSA 165:1-e) Applicant Signature Date Spouse or Co-applicant Signature Date Signature of person completing form (if not applicant) Date Town of Milton, N.H. Application for Assistance Page 9

10 AUTHORIZATION FOR THE RELEASE OF INFORMATION DHHS I,, the undersigned, understand that from time to time, Print Your Name the Welfare Administrator for the town of Milton, N.H., may require certain information about assistance I am applying for or receiving from the New Hampshire Department of Health and Human Services, Division of Family Assistance (DFA). When information cannot be provided by me personally, I hereby authorize DFA to release the following information to the local welfare administrator for the specific purposes outlined below: Type of Information Date of DFA application(s), type(s) of assistance applied for, date of eligibility determination, expected date of benefit issuance, amount of cash grant (if applicable) and/or the reason my case closed or my application was denied Date my Medicaid case opened and my Medicaid Identification Number(s) Date of any sanction of my cash assistance grant Reason for any sanction of my cash assistance grant Purpose for Requesting this Information Basic administration of my local welfare assistance case including verification of information provided by me for determining eligibility for local welfare assistance Processing of Medicaid reimbursements if/when, during the time my Medicaid application was pending, the local welfare administrator makes an expenditure on my behalf for an item covered by Medicaid Determining countable household income also called deeming Helping me to remove the sanction I understand that I have the option to provide any or all of the requested information myself. I understand that any use of the above information inconsistent with these purposes is forbidden. I understand that the local welfare administrator may not release information provided under this authorization to any other person without my written permission. This authorization shall expire 180 days from the date it is signed. Signature Date If the signature above is not that of the person to whom the requested information pertains, the relationship of the signer to that person must be indicated, the signature must be witnessed, and verification that the signer has the authority to represent the person in these matters with DFA must be provided upon DFA request. Relationship to You Witness Date Town of Milton, N.H. Application for Assistance Page 10

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